Commercial Auto Insurance – Quick Quote

Please fill out the form below and we will be in touch as soon as possible.

If you have any questions, you can contact our underwriting department at 877-243-8181 or quotes@primeis.com.

If you’d like to fill out the full online application, please click here.

COMMERCIAL AUTO APPLICATION QUICK QUOTE

Step 1 of 5

20%

1. General Information

Applicant's name:*

FirstLast

Proposed Effective Date:*

E-Mail:*

Business telephone number:*

Producer's name:*

FirstLast

Detailed description of business activities (specifically, and by location):*

Applicant is:*

Individual

Corporation

Partnership

Joint Venture

What year was the business established?*

Annual payroll:*

Total number of employees:*

Full-time:*

Part-time:*

2. Insurance History

Who is your current insurance carrier (or your last if no current provider)?*

Provide name(s) for all insurance companies that have provided Applicant insurance for the last three years

Coverage

Company name

Expiration date

Annual premium

Has the Applicant or any predecessor ever had a claim?*

Yes

No

If yes, please provide details:*

4. Desired Insurance

Per person/ per act/ property damage*

$15,000/$30,000/$5,000

$25,000/$50,000/$10,000

$50,000/$100,000/$25,000

$100,000/$250,000/$100,000

$100,000/$300,000/$50,000

$250,000/$500,000/$100,000

$250,000/$1,000,000/$100,000

Single limit $300,000

Single limit $500,000

Single limit $1,000,000

Single limit $5,000,000

Self-Insured Retention (SIR):*

$1000 (Minimum)

$1,500

$2,500

$5,000

$10,000

Physical Damage Deductible:*

$500

$750

$1,000

$5,000

Value of unit(s)?:

5. Business Operations

Type of vehicle(s) used:

How many vehicles?*

How many drivers?

What is the maximum radius of your operation?*

0-50 miles

50-100 miles

100+ miles

To what cities do you travel?*

Describe safety procedures in detail. If you have written policies and procedures, or an employee manual, please include a copy.*

Written policies and procedures, or employee manual.

The “Applicant” is the party to be named as the "Insured" in any insuring contract if issued. By signing this Application, the Applicant for insurance hereby represents and warrants that the information provided in the Application, together with all supplemental information and documents provided in conjunction with the Application, is true, correct, inclusive of all relevant and material information necessary for the Insurer to accurately and completely assess the Application, and is not misleading in any way. The Applicant further represents that the Applicant understands and agrees as follows: (i) the Insurer can and will rely upon the Application and supplemental information provided by the Applicant, and any other relevant information, to assess the Applicant’s request for insurance coverage and to quote and potentially bind, price, and provide coverage; (ii) the Application and all supplemental information and documents provided in conjunction with the Application are warranties that will become a part of any coverage contract that may be issued; (iii) the submission of an Application or the payment of any premium does not obligate the Insurer to quote, bind, or provide insurance coverage; and (iv) in the event the Applicant has or does provide any false, misleading, or incomplete information with the intent to deceive or materially affect the risk or hazard assumed by the Company in conjunction with the Application, any coverage provided will be deemed void from initial issuance.
The Applicant hereby authorizes the Insurer and its agents to gather any additional information the Insurer deems necessary to process the Application for quoting, binding, pricing, and providing insurance coverage including, but not limited to, gathering information from federal, state, and industry regulatory authorities, insurers, creditors, customers, financial institutions, and credit rating agencies. The Insurer has no obligation to gather any information nor verify any information received from the Applicant or any other person or entity. The Applicant expressly authorizes the release of information regarding the Applicant’s losses, financial information, or any regulatory compliance issues to this Insurer in conjunction with consideration of the Application.
In the event coverage is offered, such coverage will not become effective until the Insurer’s accounting office receives the required premium payment.
The Applicant agrees that the Insurer and any party from whom the Insurer may request information in conjunction with the Application may treat the Applicant’s facsimile signature on the Application as an original signature for all purposes.